cms_WV: 5961
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5961 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 329 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure three (3) of five (5) residents reviewed for the care area of unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), were free of unnecessary medications. Resident #23 had not been considered for a gradual dose reduction of an antipsychotic medication. The facility failed to adequately monitor Resident #5's use of a medication which required a pulse be taken prior to administration. Behavioral symptoms and side effects regarding the use of an antipsychotic medication were not monitored for Resident #46. Resident Identifiers: #23, #5, and #46. Facility Census: 64. Findings include: a) Resident #23 A medical record review, at 4:32 p.m. on 07/29/14, revealed the resident had a physician's orders [REDACTED]. This dose of [MEDICATION NAME] was originally ordered on [DATE], and Resident #23 continued to receive this daily dosage of [MEDICATION NAME]. Further review revealed the resident had been receiving [MEDICATION NAME] oral capsule 40 mg from 05/15/10 until 08/08/11, at which time the [MEDICATION NAME] was reduced to 20 mg a day. Review of the drug regimen reviews, completed by the pharmacist on a monthly basis, revealed the last gradual dose reduction (GDR) of Resident #23's [MEDICATION NAME] was recommended by the pharmacist on 10/09/12. The physician responded to this recommendation by saying, The resident has had a good response to treatment and requires this dose for condition stability. Dose reduction at this time would be contraindicated because benefits outweigh the risks for this patient and reduction is likely to impair the resident function and or cause psychiatric instability. As of 07/29/14, there was no evidence a GDR of [MEDICATION NAME] was recommended, attempted, and/or addressed as clinically contraindicated since 10/09/12. An interview with Registered Nurse (RN) #101, at 9:30 a.m. on 07/30/14, confirmed Resident #23 had not had a GDR recommended, attempted, and/or addressed as clinically contraindicated since 10/09/12. The Vice President of Health Services (VPHS) also stated, at 11:36 a.m. on 08/04/14, he did not see a recommendation, attempt, or that a GDR was addressed by the physician as clinically contraindicated since 10/09/12. In an interview with the consultant pharmacist, at 3:20 p.m. on 08/04/14, he stated a GDR of an antipsychotic medication should be made annually if the resident had been on the medication for longer than one (1) year. He stated even if the physician previously indicated a GDR would be clinically contraindicated, it should still be recommended and either attempted and/or addressed as clinically contraindicated by the physician. He stated if Resident #23 had not had these recommendations since 10/09/12, then it was something he must have missed. b) Resident #5 Review of Resident #5's medical record, at 9:52 a.m. on 08/04/14, revealed a physician's orders [REDACTED]. Resident #5 received this medication due to a [DIAGNOSES REDACTED]. Resident #5's medication administration records and vital sign records were reviewed for the months of May 2014, June 2014 and July 2014. There was no evidence the resident's pulse was obtained prior to the administration of [MEDICATION NAME] on 05/01/14, 05/04/14, 05/10/14, 05/13/14, 05/17/14, 05/19/14, 05/22/14, 05/28/14, 05/29/14, 05/30/14, 06/04/14, 06/15/14, 06/20/14, 06/24/14, 06/29/14, 06/30/14, 07/08/14, 07/12/14, 07/13/14, 07/17/14, 07/18/14, 07/28/14, 07/29/14, and 07/31/14. Interview with the VPHS, at 8:34 a.m. on 08/05/14, confirmed there was no evidence Resident #5's pulse was obtained prior to the administration of [MEDICATION NAME] on the previously mentioned dates. He stated, It looks as if they are giving the medication without obtaining a pulse prior to administering the medication and there is no way to tell if (Resident's name) has received this medication unnecessarily. c) Resident #46Medical record review found the resident was receiving the antipsychotic medication [MEDICATION NAME] 25 mg at night for a [DIAGNOSES REDACTED].Review of the facility's psychopharmacological drug monthly flow records revealed the resident did not have a sheet to describe the targeted behaviors to monitor and also no identified side effects for which the resident needed to be monitored.During an interview, on 08/03/14 at 3:00 p.m., the VPHS said the psychopharmacological drug monthly flow records were where staff were supposed to indicate monitoring for targeted behaviors and side effects. At that time, the VPHS acknowledged Resident #46 did not have a psychopharmacological drug flow sheet for [MEDICATION NAME]. The resident was not being monitored for the use of the [MEDICATION NAME]. | 2018-05-01 |